Penile cancer

Squamous cell carcinoma of the penis is a rare malignancy,
accounting for approximately 0.4% to 0.6% of all malignancies among
men in the United States.

Risk factors

It is commonest in men in their 60's, and in Asia, Africa and S.
America where it can reach rates of 10-20%.

It can be caused by phimosis and poor genital hygiene.
Circumcisions in newborns results in almost 100% protection.

It can be associated with HPV e.g. PCR studies have identified a
50% incidence of HPV type 16 (most common type) in invasive SCC, 90%
in CIS (most contain E6 - E7 portions).

Psoralens and UV radiation treatment also results in increased
risk.

Up to 40% of patients with SCC penis have a history of a
pre-existing penile lesion.

Cutaneous horn

Balanitis Xerotica Oblitarans (lichen sclerosis et atropicus)

Leukoplakia

Bowenoid papulosis

Condyloma acuminatum

Karposi's Sarcoma

Buscheke-Lowenstein tumour

Carcinoma in situ

Bowens disease

Clinical picture

The usual presentation is a painless sore or ulcer on the prepuce
or glans. Otherwise it can be balanoposthitis and discharge, or
rarely lymphadenopathy. Assessment of the primary disease is via a
biopsy and local invasion assessment can be assisted by US or MRI.

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Treatment

For lesions limited to the foreskin, wide local excision with
circumcision may be adequate therapy for control.

For carcinoma in situ of the glans (also referred to as
erythroplasia of Queyrat or Bowen's disease of the penis), with or
without adjacent skin involvement, therapeutic options include:

Local applications of fluorouracil cream.

Microscopically controlled surgery.

For infiltrating tumors of the glans, with or without involvement
of the adjacent skin, the choice of therapy is dictated by tumor
size, extent of infiltration, and degree of tumor destruction of
normal tissue. Equivalent therapeutic options include:

Penile amputation.

Irradiation (external-beam, brachytherapy).

Microscopically controlled surgery.

Stage II penile cancer is most frequently managed by penile
amputation for local control. Whether the amputation is partial,
total, or radical will depend on the extent and location of the
neoplasm. Radiation therapy with surgical salvage is an alternative
approach.

Inguinal adenopathy in patients with penile cancer is common but
may be the result of infection rather than neoplasm. If palpable
enlarged lymph nodes exist three or more weeks after removal of the
infected primary lesion and a course of antibiotic therapy,
bilateral inguinal lymph node dissection should be performed.

In cases of proven regional inguinal lymph node metastasis
without evidence of distant spread, bilateral ilioinguinal
dissection is the treatment of choice.[1-4] However, since many
patients with positive lymph nodes are not cured, clinical trials
may be appropriate.

There is no standard treatment that is curative for patients with
stage IV penile cancer. Therapy is directed at palliation, which may
be achieved either with surgery or radiation therapy.

Standard treatment options:

Palliative surgery may be considered for control of the local
penile lesion and even for the prevention of the necrosis,
infection, and hemorrhage which can result from neglected regional
adenopathy.

Irradiation may be palliative for the primary tumor, regional
adenopathy, and bone metastases.
Treatment options under clinical evaluation:

Clinical trials combining chemotherapy with palliative methods of
local control are appropriate for such patients (tested
chemotherapeutic drugs with some efficacy include vincristine,
cisplatin, methotrexate, and bleomycin). The combination of
vincristine, bleomycin, and methotrexate has been effective both as
adjuvant and neoadjuvant therapy.